School‐based interventions on Mpox: A scoping review

Abstract Background and Aims The 2022 multicountry mpox outbreak necessitated the declaration of mpox as a public health emergency. This is the first time a wide mpox spread and human‐to‐human transmission are recorded in several countries outside West and Central Africa. The outbreak reveals a strong need for wider intervention to increase awareness and control measures on mpox, especially in schools. This scoping review aims to summarize the existing evidence concerning school‐based interventions on mpox globally. Methods The review methodology was based on the Arksey and O'Malley guidelines and it was reported in strict adherence with the PRISMA‐ScR checklist. Ten databases were searched to retrieve literature relevant to the review topic. Thereafter, the retrieved literature were deduplicated and screened for inclusion into the review based on a set of eligibility criteria. Only one journal paper, a short communication on the national monkeypox outbreak in England, satisfied the selection criteria and was included in the review. Data extracted from the included paper were collated, summarized, and presented. Results The paper described how suspected cases of mpox infection were managed in some school settings through vaccination and self‐isolation approaches and revealed a low (11%) mpox vaccination uptake rate in school‐setting. The preventive methods adopted, such as the exclusion of exposed persons from school (in three school settings) and separation of those exposed those who were not in contact with the affected persons (one school setting), played a major role in the low transmission rate reported. This review also found a huge dearth of literature on school‐based interventions on mpox despite its global spread. Conclusion With the call for a multisectoral approach in the fight against mpox, it pays to leverage on the potential of school settings in public health actions against mpox.


| INTRODUCTION
The monkeypox (now known as mpox) virus, first identified in 1970, is an orthopoxvirus, which causes infections with symptoms similar to smallpox, although less severe. 1 Mpox is traditionally found in countries of central and west Africa with confirmed cases in the Central African Republic, Democratic Republic of the Congo, Liberia, Nigeria, Republic of the Congo, and Sierra Leone. 2 Unfortunately, most of the mpox endemic countries do not have adequate control infrastructure for prevention, detection and prevention. 3 Mpox is mostly transmitted from animals (such as squirrels, Gambian pouched rats, dormice, different species of monkeys and others) to humans.
Human-to-human transmission occurs through contact with body fluids (including sexual contacts), lesions on the skin or internal mucosal surfaces (in the mouth or throat), respiratory droplets and contaminated objects. 4,5 Globalization, a major driver of human mobility, has opened up the world, which incidentally facilitates the transmission of infectious diseases. 6 Most infectious diseases constitute significant and acute global health challenges. Predictably, the multicountry outbreak (including Europe and North America) of mpox necessitated the declaration of mpox as a public health emergency. 5 As of the end of January 2023, the 2022 outbreak has resulted in 85,499 confirmed cases in 110 countries with 89 deaths. 7 The spread has cut across the globe with the 10 most affected countries, accounting for over 85% being outside Africa including the United States of America with 29,891 cases, Brazil with 10,739 cases;, Spain with 7518 cases, France with 4128 cases, Colombia with 4066 cases, Mexico with 768 cases, the United Kingdom with 3735 cases, Peru with 3723 cases, Germany with 3692 cases, and Canada with 1460 cases. 7 Venkatesan 5 observed that the 2022 mpox outbreak has the highest recorded incidence compared to previous outbreaks. It is also the first time there is high incidence outside the West and Central Africa.
The data shows a strong need for wider intervention to increase awareness and induce appropriate responses from the global population.
Globally, there is a low prevalence of mpox among school-aged children 8,9 but intense and possibly prolonged physical contact among the school-aged in schools and during activities such as sports and plays constitute a significant concern for any infectious diseases including mpox and COVID-19 among others. Sam-Agudu et al. 9 reported an mpox epidemiological transition, initially with high prevalence among children (under 10 years old) but now more prevalent among adults and sexual minorities. The global prevalence among children is less than 2% but up to 40% among children in Africa. 7 Children and adults also account for the highest mortality rates in Africa. 9 While there is a strong need for multisectoral intervention, one significant way of reaching a wider population is a school-based approach. 10,11 A school-based intervention depicts measures implemented in classrooms or in schools to improve health and wellbeing and reducing risk or problem behavior of the students. 12 School-based intervention is a significant way of reaching school-aged children which could be an indirect way of reaching their parents and other household members. 13 Such an approach will enhance information spread and a form of engagement, with a significant effect on preventive and control actions. 14 The school-based approach is also pertinent because of the sexual dimension in mpox transmission.
The school setting has always been a significant space for health promotion to curtail the prevalence of both chronic and infectious diseases. The ultimate goal of health intervention in the school setting is to improve knowledge of risk factors, promote appropriate health behavior through personal interiorization of health knowledge and critical thinking about harmful effects of common risky behaviors. [15][16][17] Pulimeno et al. 16 observed that health promotion within the school setting could reduce the prevalence of measurable unhealthy outcomes and improve academic achievements. It is always a case of primary prevention and health promotion targeting early life and the school is an ideal setting of action. 16 It is pertinent that several studies, including scoping reviews, have been conducted on mpox [18][19][20] ; however, no known scoping review has been conducted as of the first quarter of 2023 to summarize evidence on school-based interventions on the disease. The need for such scoping review evidence is very crucial as such findings will set the pace for further research on mpox prevention and control, and it will also inform the public health planning, implementation, and evaluation of future schoolbased interventions on mpox. Hence, this study aims to conduct a scoping review of evidence on school-based interventions on mpox across the world.

| Title and protocol registration and deviations from the protocol
The title and protocol of this scoping review was initially registered as systematic review with PROSPERO (CRD42023409593). However, we deviated from the initial protocol and changed the study design to a scoping review due to the appropriateness of a scoping review for this study. 21

| Review design
The rationale of this scoping review was to summarize the existing research evidence on school-based interventions on Mpox. 21 This review's methodology was based on the Arksey and O'Malley's 22 guidelines for scoping reviews, and it was reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews checklist. 23 Additionally, the quality of this review's methodological process was ensured through strict adherence to the guidelines prescribed in the AMSTAR-2 checklist. 24

Exclusion criteria
The criteria for the exclusion of literature into this scoping review are the following: 1. Publications that are not in peer-reviewed journals (e.g., books, book chapters, media news reports, etc.). and without year and language limiters. The search strings used for the search strategy are illustrated in the Appendix (Tables A1, A2 and A3).

| Data charting, collation, and summarization
Relevant data, including citation data (authors' names and publication year), study design, study objectives, study's location, population under study, sample size, findings, and conclusions, were charted from the included article by two reviewers using a bespoke data extraction sheet. Thereafter, the extracted data were collated, summarized and presented as results.

| RESULTS
A total number of 264 publications were retrieved from the 10 databases, with the largest number of retrieved publications obtained from SCOPUS (n = 240) ( Table 1)

| MPox prevention and control
The preventive method reported in the only included paper 26 such as the exclusion of exposed persons from school (in three school settings) and separation of those exposed those who were not in contact with the affected persons (one school setting) played major parts in the low transmission rate reported. In all the affected schools, self-isolation at home was not recommended or adopted. Other preventive strategies that helped to contain mpox spread include vaccination of high-risk students. Ladhani et al. 26

| Evidence/research gaps
Only one report on the national monkeypox outbreak in England satisfied the selection criteria and was assessed in this review.
Although, the eligible publication is a nonintervention study as it reported epidemiological and surveillance information. It described how suspected cases of mpox infection were managed in some school settings. This review indicates a major gap in literature specifically, the research gap on school-based interventions on mpox infection. Results from this scoping review did not reveal whether any intervention programs on mpox were introduced in the affected schools and whether such intervention had significant effects on low mpox transmission among young children. 26 While the authors reported low vaccine uptake, reasons for the low uptake were not reported and no study focused on this aspect of mpox control was identified in our review. Apart from isolation, Ladhani et al. did not report other preventive mechanisms adopted in the study population.
Furthermore, given the high risks that young school students are The study documented that mpox transmission occurs through sexual contact among sexual minorities (both penetrative and nonpenetrative), more than casual skin-to-skin contact. 32 The study reviewed here reported epidemiology and mpox outbreak management strategies and infection prevention and control efforts in some school settings in England subsequent to four different cases of exposure. Following the 28-day follow-up window which involved isolation and separation of no less than 440 exposed persons, zero case of mpox infection was identified as none of the low, medium, and high-risk groups were infected. This Probable community transmission of infectious diseases through the school settings is always a public health concern because school children and young adults up to the secondary school level constitute a significant percentage of the population. 35 Notwithstanding the low

ACKNOWLEDGMENTS
This study was self-funded.

Kehinde K. Kanmodi is an Editorial Board member of Health Science
Reports and a coauthor of this article. To minimize bias, he was excluded from all editorial decision-making related to the acceptance of this article for publication. The authors declare no conflict of interest.

DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no new data were created or analyzed in this study.

ETHICS STATEMENT
This study did not collect data from human or animal subjects but an open research repository.

TRANSPARENCY STATEMENT
The